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A BILL TO BE ENTITLED
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AN ACT
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relating to the reporting of claims information under certain |
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health benefit plans; providing administrative penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 8, Insurance Code, is amended |
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by adding Chapter 1215 to read as follows: |
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CHAPTER 1215. REPORTING OF CLAIMS INFORMATION |
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Sec. 1215.001. DEFINITIONS. In this chapter: |
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(1) "Employer" has the meaning assigned by 29 U.S.C. |
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Section 1002(5). |
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(2) "Governmental entity" means a state agency or |
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political subdivision of this state. |
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(3) "Group health plan" has the meaning assigned by 45 |
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C.F.R. Section 160.103. |
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(4) "Health benefit plan issuer" means a health |
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insurance issuer or a health maintenance organization. |
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(5) "Health insurance issuer" has the meaning assigned |
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by 45 C.F.R. Section 160.103. |
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(6) "Health maintenance organization" has the meaning |
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assigned by 45 C.F.R. Section 160.103. |
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(7) "Plan" means an employee welfare benefit plan as |
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defined by 29 U.S.C. Section 1002(1). |
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(8) "Plan administrator" means an administrator as |
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defined by 29 U.S.C. Section 1002(16)(A). |
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(9) "Plan sponsor" has the meaning assigned by 29 |
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U.S.C. Section 1002(16)(B). |
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(10) "Political subdivision" means a county, |
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municipality, school district, special-purpose district, or other |
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subdivision of state government that has jurisdiction limited to a |
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geographic portion of the state. |
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(11) "Protected health information" has the meaning |
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assigned by 45 C.F.R. Section 160.103. |
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Sec. 1215.002. APPLICABILITY OF CHAPTER TO POLITICAL |
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SUBDIVISIONS; APPLICABILITY OF OTHER LAW WITH REFERENCE TO |
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POLITICAL SUBDIVISIONS. (a) This chapter applies to a |
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governmental entity that enters into a contract with a health |
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benefit plan issuer that results in the health benefit plan issuer |
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delivering, issuing for delivery, or renewing a group health plan. |
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(b) For purposes of this chapter, a health benefit plan |
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issuer shall treat a governmental entity described by Subsection |
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(a) as a plan sponsor or plan administrator. |
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(c) A report of claim information provided under this |
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section to a governmental entity is confidential and exempt from |
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public disclosure under Chapter 552, Government Code. |
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Sec. 1215.003. RECEIPT OF AND RESPONSE TO REQUEST FOR CLAIM |
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INFORMATION. (a) Not later than the 30th day after the date a |
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health benefit plan issuer receives a written request for a written |
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report of claim information from a plan, plan sponsor, or plan |
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administrator, the health benefit plan issuer shall provide the |
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requesting party the report, subject to Subsection (c). |
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(b) A report of claim information provided under Subsection |
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(a) must contain all information available to the health benefit |
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plan issuer that is responsive to the request made under Subsection |
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(a), including protected health information, for the 36-month |
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period preceding the date of the request or for the entire period of |
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coverage, whichever period is shorter. A report provided under |
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Subsection (a) must include: |
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(1) aggregate paid claims experience by month, |
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including claims experience for medical, dental, and pharmacy |
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benefits, as applicable; |
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(2) total premium paid by month; |
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(3) total number of covered employees on a monthly |
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basis by coverage tier, including whether coverage was for: |
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(A) an employee only; |
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(B) an employee with dependents only; |
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(C) an employee with a spouse only; or |
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(D) an employee with a spouse and dependents; and |
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(4) a separate description of any claim exceeding |
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$10,000, including the following information related to the claim: |
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(A) a unique identifying number, characteristic, |
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or code; |
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(B) the amounts paid; |
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(C) dates of service; |
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(D) applicable diagnosis codes; and |
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(E) prognosis or, if not available, case |
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management notes, including any future expected costs and treatment |
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plan, that relate to the claim. |
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(c) A plan sponsor is entitled to receive protected health |
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information under this section only after an appropriately |
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authorized representative of the plan sponsor makes the following |
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certification to the health benefit plan issuer: |
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"I hereby certify that the plan documents comply with the |
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requirements of 45 C.F.R. Section 164.504(f)(2) and that the plan |
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sponsor will safeguard and limit the use and disclosure of |
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protected health information that the plan sponsor may receive from |
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the group health plan to perform the plan administration |
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functions." |
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(d) In the case of a request made under Subsection (a) after |
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the date of termination of coverage, the report must contain all |
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information available to the health benefit plan issuer as of the |
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date of the request that is responsive to the request, including |
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protected health information, and including the information |
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described by Subsections (b)(1)-(4), for the 36-month period |
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preceding the date of termination of coverage or for the entire |
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policy period, whichever period is shorter. |
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(e) A report of claim information provided under Subsection |
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(a) and described by Subsections (b)(1)-(4) or (d) must include the |
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total dollar amount of claims pending as of the date of the report |
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that were first filed during the 24-month period preceding the date |
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of the request or for the entire period of coverage, whichever |
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period is shorter. |
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(f) Not later than the 30th day after the date of |
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termination of coverage under a group health plan, a health benefit |
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plan issuer shall provide to a plan, plan sponsor, or plan |
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administrator who makes a request under Subsection (a) before the |
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date of termination of coverage a supplemental written report of |
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the information described by Subsections (b)(1)-(4) and (d), |
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including protected health information, to update the report of |
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claim information with information that was not included in the |
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original report provided under Subsection (a). |
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(g) A plan, plan sponsor, or plan administrator must request |
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a report under Subsection (a) before or on the second anniversary of |
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the date of termination of coverage under a group health plan issued |
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by the health benefit plan issuer. |
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Sec. 1215.004. USE OF INFORMATION BY CERTAIN PARTIES. A |
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plan, plan sponsor, or plan administrator may use information in a |
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written report of claim information provided under this chapter |
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only as necessary to perform treatment, payment, or health care |
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operations as those activities are described by 45 C.F.R. Section |
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164.501. |
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Sec. 1215.005. COMPLIANCE WITH CHAPTER DOES NOT CREATE |
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LIABILITY. A health benefit plan issuer that releases information, |
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including protected health information, in accordance with this |
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chapter has not violated a standard of care and is not liable for |
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civil damages resulting from, and is not subject to criminal |
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prosecution for, releasing that information. |
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Sec. 1215.006. ADMINISTRATIVE PENALTIES. A health benefit |
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plan issuer that does not comply with this chapter is subject to |
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administrative penalties under Chapter 84. |
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SECTION 2. The following laws are repealed: |
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(1) Article 21.49-15, Insurance Code; |
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(2) Chapter 1209, Insurance Code; and |
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(3) Section 1501.614, Insurance Code. |
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SECTION 3. The change in law made by this Act applies only |
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to a report of claim information that is requested on or after the |
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effective date of this Act. A report of claim information that is |
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requested before the effective date of this Act is governed by the |
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law as it existed before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2007. |